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Eur Child Adolesc Psychiatry (2005) 14:174–180 DOI 10.1007/s00787-005-0457-8

Mirjami Pelkonen Mauri Marttunen Markus Henriksson Jouko Lönnqvist

Accepted: 3 December 2004

M. Pelkonen, Ph.D. (
) · M. Marttunen, M.D., Ph.D. · J. Lönnqvist, M.D., Ph.D. Department of Mental Health and Alcohol Research National Public Health Institute Mannerheimintie 166 00300 Helsinki, Finland Tel.: +358-9/47448213 Fax: +358-9/47448478 E-Mail: [email protected] M. Pelkonen, Ph.D. · M. Marttunen, M.D., Ph.D. Department of Adolescent Psychiatry Peijas Hospital Helsinki University Hospital Vantaa, Finland M. Marttunen, M.D., Ph.D. Department of Psychiatry University of Oulu Oulu, Finland

ORIGINAL CONTRIBUTION

Suicidality in adjustment disorder Clinical characteristics of adolescent outpatients

M. Henriksson, M.D., Ph.D. Central Military Hospital Finnish Defence Forces Helsinki, Finland

■ Abstract Objective Although a remarkable proportion of adolescents suffering from adjustment disorder (AD) are suicidal, few studies have documented the characteristics of suicidal AD patients. We examined background, psychopathology and treatment-related factors among suicidal adolescent AD outpatients. Method Data on 302 consecutively referred psychiatric outpatient adolescents, aged 12–22 years, were collected. DSM-III-R diagnoses were assigned at the end of treatment based on all available data. Of the patients 89 received a diagnosis of AD, 25 % of whom showed suicide

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Introduction The relationship between major psychiatric disorders and suicidal behaviour is well established [5, 15, 29]. However, findings on the relationship between less severe psychiatric conditions and suicidal behaviour are less consistent [15]. Adjustment disorders (AD), a diagnostic category in DSM-IV [2], consist of maladaptive reactions followed by a psychosocial stressor and not meeting criteria for more specific disorders.Although AD has been regarded as a “transitional, or marginal diagnostic category” [14],

attempts, suicidal threats or ideation. Results Compared with non-suicidal AD patients, suicidal AD patients were characterized by previous psychiatric treatment (OR = 6.1), poor psychosocial functioning at treatment entry (OR = 16.2), suicide as a stressor (OR = 33.3), dysphoric mood (OR = 6.9) and psychomotor restlessness (OR = 3.7). Conclusions Common risk factors for suicidality in major psychiatric disorders characterized suicidal AD patients. Psychiatric assessment of AD patients should include careful monitoring of both symptomatology and exposure to suicide of significant others. ■ Key words suicidality – adolescence – adjustment disorder – psychiatric treatment – precipitant stressors

there are also reports of it being a common and serious condition among adolescents [3, 10, 26]. Despite the lack of a specific symptom profile for AD in the diagnostic criteria, suicidal behaviour appears to be prominent among AD patients of all ages [3, 12, 17, 19, 23, 24, 26, 33, 35, 39]. Psychological autopsy studies have found that up to one fifth of adolescent suicide victims may have an adjustment disorder [21, 22, 34]. Although an AD subtype with suicidal behaviour was proposed for inclusion in DSM-IV, it was decided that this would discourage a more systematic assessment of symptoms in patients presenting with suicidal behaviour [25]. In clinical populations the number of suicidal young

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people with AD has varied between one fifth and one half [3, 17, 18, 36].Although AD is found to be a relatively common psychiatric disorder in clinical practice and that suicidal behaviour is prevalent in adolescents with this disorder, research characterizing suicidal AD patients, particularly outpatients, is scarce. In our previous report on consecutively referred outpatient adolescents, AD was the second most common diagnosis, and one quarter of those with AD had suicidal behaviour (Pelkonen et al. submitted). The present study set out to examine the associations between suicidal tendencies and psychosocial background, precipitant stressors, symptoms of psychopathology, behavioural problems and treatment-related factors in AD patients.

Methods We studied adolescents, aged 12–22 years, referred for their first treatment at a psychiatric outpatient secondary care clinic for adolescents during the five-year period 1990–1994, and whose index treatment was completed by the end of May 2000. Of the 302 adolescents referred during this time, 89 received a psychiatric diagnosis of AD and were included in the study analyses. The catchment area of the clinic covers the approximately 220,000 inhabitants (15 % adolescents) of Vantaa and Kerava, mixed urban and suburban townships close to Helsinki, the capital of Finland. The clinic offers eclectic psychiatric treatment, including individual psychotherapy, family consultations and psychotropic medication as appropriate. The clinic contact usually begins with a phone call from an adolescent, his or her parent, or a health or social care professional. Adolescents are initially screened by a psychiatric staff member in one or more telephone interviews lasting 15–45 minutes. Information on the major problems reported during the initial phone call was classified for this study as externalizing symptoms (e. g. stealing, aggressive behaviour) or internalizing symptoms (e. g. depressive feelings, interpersonal problems, anxiety), and based on the semistructured phone data coding sheets.

■ Data collection The data collection procedure has been described previously [28]. Briefly, during the first two appointments information was gathered by psychiatric staff members on family-related characteristics, the adolescents’ previous psychiatric treatment, current life situation, the referring person, and on previous and current suicidal ideation and suicide attempts. The adolescent and parents were asked whether and when he/she had thought of or threatened suicide, or tried to kill himself/herself.

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Subjects with previous or current suicide attempts, suicide threats or suicide ideation were coded as suicidal. The level of the patient’s psychosocial functioning was assessed with the Global Assessment Scale (GAS) [13], applying the ten-class version used in Finland [20]. GAS has proved a reliable measure of psychosocial functioning in adolescents [28]. At the end of the treatment the following data were gathered: number of scheduled and kept individual and family appointments, psychotropic medication, suicidal ideation and suicide attempts during the treatment, level of psychosocial functioning and recommended aftercare. The final psychiatric diagnoses according to DSMIII-R criteria [1] were assigned by the treating psychiatrist at the end of treatment, and confirmed by a senior psychiatrist (MM). Multiple diagnoses on DSM-III-R axes I and II were allowed. Among the patients with adjustment disorders, the stressors were considered in the diagnostic procedure, and the final assessment was made by one researcher (MP) from medical charts. The stress-related event (parent-related, peer-related, financial, school/work problems and others) was classified (no/yes) as a precipitant stressor if it was considered evident that it had directly contributed to the adolescent’s psychic suffering. The number of stressors, and in cases of multiple stressors the most severe of them (main stressor), was also noted. An open recording of stressors was used. Data on psychic distress symptoms and behavioural problems (alcohol misuse, drugs, school problems, learning difficulties, aggressive behaviour) were coded (no/yes) retrospectively from medical charts. The assessments were based on the clinician’s judgements, and final assessment was made by the researcher (MP). Psychic distress symptoms included dysphoric mood, sleep difficulties, psychomotor restlessness, concentration problems, feelings of self-reproach and anxiety symptoms, each recorded as no/yes.

■ Statistical analysis When comparing suicidal and non-suicidal AD patients, cross-tabulations in the descriptive part of the data analysis were performed using the Chi-square or Fisher’s exact test, depending on the form of the table and sample size. Equality of the means was tested using the t-test. Stepwise logistic regression modeling was used to select variables associated with the dependent variable when analyzing the response with two classes. The results are supported by OR ratios using 95 % confidence intervals. In interpreting the results the level of significance was set equal to 0.05. The computations were performed using SPSS/Win for PCs.

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■ Stressors, distress symptoms and behavioural problems

Results ■ Psychosocial background There was no difference in mean age between suicidal and non-suicidal AD patients (16.0 yrs vs. 15.6 yrs, respectively), or in the proportion of females (61.2 % vs. 68.2 %). Suicidal AD patients were more severely impaired at treatment entry, and had previously utilized psychiatric services more often than non-suicidal AD patients (Table 1).

There was no difference in the mean number of all stressors between suicidal and non-suicidal AD patients (mean 4.3 vs. 4, respectively). The main stressors among suicidal AD patients were parent-related in one half and peer-related in one third. No difference was found in diagnostic co-morbidity between suicidal and non-suicidal AD patients. However, suicidal AD patients more often had substance misuse, aggressive behaviour and anxiety symptoms, although the differences did not reach statistical significance. Suicidal AD patients more often had suicide of a significant other as a precipitant stressor,and dysphoric mood and psychomotor restlessness compared with non-suicidal AD patients (Table 2).

Table 1 Psychosocial background and clinical characteristics of suicidal AD patients (those with suicide attempts, suicidal threats or ideation) compared with non-suicidal AD patients Family-related factors Parental divorce Living at home Low SESa Individual characteristics Male gender History of any previous psychiatric care Previous out-patient care Previous in-patient care Referring person health care professional Taken into foster care Problems with the lawb At school at treatment entry Clinical characteristics Internalizing symptoms as reason for referral Co-morbid psychiatric diagnosisc Psychotropic medication Recommended for admission to psychiatric hospital Individual psychotherapy Treatment adherence Non-adherentd Referred Adherent

Psychosocial functioning (GAS) at treatment entryf Psychosocial functioning (GAS) at last appointmentf Number of appointments a

Suicidal AD patients (n = 22)

Non-suicidal AD patients (n = 67)

N

%

N

%

p

16 17 17

72.7 77.3 77.3

38 58 46

56.7 86.6 68.7

0.182 0.299 0.441

7 11 10 3 7 3 3 19

31.8 50.0 45.5 13.6 31.8 13.6 13.6 86.4

26 15 15 0 13 2 9 63

38.8 22.4 22.4 0.0 19.4 3.0 13.4 94.0

0.556 0.013 0.037 0.002 0.226 0.060 0.981 0.246

20 2 1 0 8

90.9 9.1 4.5 0.0 36.4

55 2 1 0 16

82.1 3.0 1.5 0.0 23.9

0.324 0.230 0.435

10 1 11

45.5 4.5 50.0

21 1 45

31.3 1.5 67.2

Mean (range), SD

Mean (range), SD

4.9 (3–7), 1.1 5.6 (4–8), 1.1 10.7 (1–52), 12.3

5.4 (4–6), 0.7 6.0 (4–8), 0.9 8.9 (1–52), 9.2

0.252 0.300e

0.010 0.062 0.453

The socioeconomic status (SES) of the adolescents’ families was based on the occupation of the parent considered as the guardian, and was first categorized with the nine-grade classification officially used in Finland [11]. For the analyses, SES was classified as high (classes 1–3) when the guardian was a self-employed worker or upper-level employee, and low (classes 4–9) when a lower-level employee or manual worker. b Adolescents who had been arrested, charged or convicted of an offence were classified as having had problems with the law. c One patient had one or more psychiatric diagnoses. d If treatment did not continue after the evaluation phase, or the key problems had not been worked through and need for care was still evident, the patient was assessed as non-adherent. e df = 2. f lower score, poorer functioning

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M. Pelkonen et al. Suicidal AD patients Table 2 Precipitant stressors, psychic distress symptoms and behavioural problems among outpatients with adjustment disorders (AD) by suicidality (those with suicide attempts, suicidal threats or ideation)

Precipitant stressors Parental death (not suicide) Parental illness Other family related event Suicide of significant other Peer related Moved School or work related Financial difficulties Other Psychic distress symptoms and behavioural problems Alcohol misuse Drug misuse School absenteeism, truancy Learning difficulties, special/remedial education Aggressive behaviour Dysphoric mood Sleep difficulties Psychomotor restlessness Concentration problems Self-reproach Anxiety symptoms

Suicidal AD patients (n = 22)

Non-suicidal AD patients (n = 67)

N

%

N

%

p

1 10 16 3 20 8 16 6 14

4.5 45.5 72.7 13.6 90.9 36.4 72.7 27.3 63.6

6 28 52 1 50 25 49 20 39

9.0 41.8 77.6 1.5 74.6 37.3 73.1 29.9 58.2

0.505 0.763 0.640 0.017 0.106 0.936 0.970 0.818 0.653

9 3 11 5

40.9 13.6 50.0 22.7

18 3 43 16

26.9 4.5 64.2 23.9

0.214 0.137 0.237 0.912

17 20 5 13 10 10 17

77.3 90.9 22.7 59.1 45.5 45.5 77.3

42 45 25 22 24 42 41

62.7 67.2 37.3 32.8 35.8 62.7 61.2

0.209 0.029 0.209 0.029 0.420 0.155 0.170

■ Treatment-related factors Suicidal and non-suicidal AD patients did not differ in terms of treatment-related variables. The mean number of appointments was 11 among suicidal AD patients. Almost half of those with suicidality dropped out prematurely from treatment.A recommendation to psychiatric inpatient treatment at the last appointment was uncommon in both patient groups (Table 1).

■ Multivariate comparisons We conducted a series of logistic regression analyses using a backward selection procedure in order to further compare AD patients with suicidal behaviour with nonsuicidal AD patients. The significant variables associated with suicidality were entered into the model. Previous psychiatric treatment (OR = 4.1, 95 % CI 1.4–12.3) and poor GAS at treatment entry (OR = 6.0, 95 % CI 1.8–20.0) characterized suicidal outpatients with AD, Goodness-of-fit Chi square 2.7, df = 2, p = 0.26. Next, we included dysphoric mood, psychomotor restlessness (Table 2) and age and sex (along with suicide as a stres-

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sor) in the model. Previous psychiatric treatment, poor GAS at treatment entry, suicide as a stressor, dysphoric mood and psychomotor restlessness remained in the model (Table 3), correctly classifying 83.2 %, including 59.1 % of those with suicidal behaviour. We further controlled the impact of other background and clinical variables by conducting a series of multivariate comparisons (data not shown). The results (Table 3) remained essentially unchanged.

■ AD patients with suicide attempts In the AD group, eight adolescents (9 % of 89) had attempted suicide. All were female, were in school at treatment entry and had internalizing symptoms as a reason for referral. None had problems with the law or co-morbid psychiatric disorders. However, 37.5 % of them had alcohol misuse, 87.5 % aggressive behaviour, 12.5 % learning difficulties and 87.5 % anxiety symptoms.

Discussion In this study of consecutively referred outpatient adolescents, we used systematically collected clinical data to characterize suicidal adolescents with adjustment disorder. We found that AD patients with suicidality comprised a group significantly different from non-suicidal AD patients, both in terms of psychopathology and stressors. Previous psychiatric morbidity and severe psychosocial impairment at treatment entry characterized the suicidal AD patients, in line with findings among adult suicidal inpatients with AD [19, 35]. If replicated in future studies among adolescents with AD, the present findings would suggest that these risk factors, known to be associated with suicidal adolescent patients with major psychiatric disorders [4, 15], also characterize those in a “minor” or “less severe” diagnostic group. We also found that dysphoric mood was associated with adolescent suicidal AD patients, as reported among Table 3 Multivariate comparisons: statistically significant predictors in individual and clinical characteristics, stressors and psychic distress symptoms associated with suicidality (those with suicide attempts, suicidal threats or ideation) among outpatients with AD (total n = 89: 22 with suicidality)

Any previous psychiatric care Poor psychosocial functioning at treatment entry Suicide as a precipitant stressor Dysphoric mood Psychomotor restlessness a OR odds ratio; b CI confidence interval

ORa

95% CIb

p

6.1 16.2 33.3 6.9 3.7

1.5–24.0 3.3–79.3 2.5–451.8 1.0–45.4 1.0–14.1

0.010 0.0001 0.008 0.045 0.052

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first-time suicide attempters with AD [16], and in adolescent populations with “sub-threshold” depressive disorders [15]. Depressed mood at baseline was also a significant factor associating with both continued suicidal ideation and reattempts among adolescent suicide attempters [37]. Moreover, depressive symptoms were common among adolescent completed suicides with adjustment disorders [22]. Besides dysphoric mood, psychomotor restlessness characterized suicidal AD patients. Psychomotor restlessness may indicate externalized anxiety and hyperarousal. Thus, regardless of different methods and sample characteristics, our findings are in line with those reporting that hospitalized adolescent suicide attempters have demonstrated high levels of such negative emotions as symptoms of depression, anxiousness and anger [27, 38]. A broad range of psychopathology, in terms of depression, anxiousness and impulsivity, also characterized depressed suicidal adolescent outpatients [41] as well as suicidal adult AD patients [19]. Moreover, one fifth of adolescent completed suicides with adjustment disorders evidenced some kind of mood instability/irritability, were easily stimulated, impulsive, and had difficulties in overcoming disappointments [21]. These findings point to the importance of thorough assessment of a wide spectrum of symptoms of intolerable negative affect arousal, including symptoms of psychomotor restlessness, among suicidal youth with adjustment disorders. Exposure to suicidal behaviour of peers [8, 9] or family members [31] is reportedly associated with subsequent psychiatric morbidity and social maladjustment. On the other hand, associations between exposure to suicide and adolescent suicidality have been less consistently found in these studies. In the present study, the findings with regard to exposure to suicide of a significant other was based on just four cases in the two groups. The low number of suicides of a significant other among AD patients means that our findings of an association with suicidality need to be seen as preliminary. However, Marttunen et al. [22] found that 55 % of adolescent suicide victims with AD had experienced one or more suicides of significant others. Unfortunately, we had no data on suicide attempts of significant others, shown to be an important risk factor for suicidal behaviour by adolescents [7, 30]. Half of all suicidal patients with AD terminated treatment prematurely, and many of them had only a brief spell of therapy, as reported previously for suicidal adolescents [32, 40]. Adolescents who drop out prematurely from treatment appear to be more at risk of subsequent suicidal behaviour [6]. Some recent studies have examined the effectiveness of specific treatments for suicidal youth [15, 29], but not for AD patients. We found that symptoms followed by stressors included mixed internalizing and externalizing features, and associated with

poor psychosocial functioning among suicidal youth with AD, presenting a challenge in developing appropriate treatment modalities for these young people.

■ Methodology The strengths of this study include the large consecutively referred adolescent outpatient population and the comprehensive data collection. In addition, the cohort was homogenous in ethnic and cultural background, and a diagnostic classification with explicit criteria (DSM-III-R) was used to assess clinical psychiatric diagnoses among the patients who attended the clinic. The diagnostic procedure with confirmation of a senior psychiatrist was not blind to other characteristics of the patients. The diagnostician was, however, blind to the specific aims of the present study. The diagnostic procedure included assessment of stressors, although no explicit criteria for stressors were used. Thus the descriptions of these features among those with adjustment disorders may have caused underestimation. Due to low frequencies in some cells the associations in multivariate analyses remained low, and thus the power for some analyses was limited. In the multivariate analyses some variables remaining in the analyses strengthened the statistical significance of the model, although the 95 % confidence intervals were wide. Finally, the results from this predominantly urban and suburban outpatient secondary care clinic for adolescents cannot be directly generalized to other populations in countries with different forms of health care services.

■ Clinical implications Among adolescent outpatients with AD, there appears to be a subgroup of suicidal young people whose psychosocial functioning is poor, who have previously received psychiatric treatment, and who have a mixed “minor” or “sub-threshold” symptom profile including depressed mood and behaviour problems. These risk factors, commonly associated with suicidality in major psychiatric disorders, seem also to be indicators of suicidality in youths with adjustment disorders. The clinical assessment of outpatient adolescents with adjustment disorder should include thorough monitoring of suicidal tendencies. We found that many suicidal AD patients displayed only suicidal ideation or threats, suggesting that clinicians should be alert to any markers of suicidal behaviour in AD patients. Psychiatric assessment of AD patients should also include monitoring of exposure to suicide of significant others.

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M. Pelkonen et al. Suicidal AD patients ■ Acknowledgments The expert statistical help of Professor Pekka Laippala, PhD, recently deceased, is greatly appreciated. Financial support: The study was supported financially by the Yrjö Jahnsson

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Foundation, Peijas Hospital and Hospital District of Helsinki and Uusimaa.

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